Tuesday, August 8, 2017

Improving Westerosi Maternity Services - Every Mummer Counts

The long awaited follow up to my argument in favour of improved Trauma Services is looking at the need for better maternity care in Westeros.


Women in Westeros get a bad deal and is this most evident in it's shocking maternal mortality rates. Whilst definitive statistics are difficult to come by there is a rich stock of qualitative data from documentary series "Game of Thrones". It shows that childbirth is dangerous and pregnancy gives no reprieve from the violence of the world.

The first major problem is access to basic medical care for even the most highborn of women. Arguably the root of Robert's Rebellion was the fact Lyanna Stark, though surrounded by willing servants in a prestigious tower died from a post partum haemorrhage. Adequate access to uterotonic medication and availability of those suitably trained in repair of perineal trauma may have averted such a tumultuous period in Westerosi history. The stigma for survivors is also a burden to be borne. Tyrion Lannister born without access to pre-natal USS screening to actively manage the pregnancy led not only to Joanna Lannister's death but also a lifetime of scorn from his remaining family.

It is no better across the Narrow Sea where perinatal mortality is also worryingly high. Added to this we have proof of non evidence based blood magic from unlicensed Maeges have been responsible for the stillbirth of Daenerys Targaryen's child. It is important that any new process or therapy is rigorously peer approved and based on sound scientific evidence and the risks of alternative therapies are communicated to women and consent gained accordingly.

The stories here are just the affluent tip of the iceberg. There will be thousands of stories of less privileged women dying in poverty due to lack of access to midwifery care and sanitation.

That's not to say there aren't successes. There is documentation of multiple births north of the wall at Craster's Keep and indeed the Queen on the Iron Throne has successfully delivered 3 children under dubious lineage. Consanguinity as a protective factor could be an interesting topic for further research?

Maternal Mortality statistics also contain deaths from indirect causes, which commonly seems to be deaths from domestic violence. This includes the recent death of Walda Bolton and her newborn son. Having successfully traversed a high risk pregnancy with a raised BMI, care in post partum time should include a thorough domestic violence risk assessment which would have surely have picked up on the dangerous individuals in her household. Without robust systems and social services in place these vulnerable people were let down by the crown.

Calls are then made for access to those with formal training in childbirth and maternity care. This surely must fall into the remit of Maesters who are ideally placed to lead maternity care. They have anatomical and pharmaceutical knowledge to make a real difference in the delivery of maternity care. However they have their own issues before being made part of the maternal health team. Being very secretive with their knowledge is not the right way to go about healthcare innovation and they would need to embrace a more open non-blame culture in improving outcomes. They would also need to evaluate their own practices against current trends to ensure that Maesterising birth doesn't lead to poor outcomes and a loss of maternal choice in their birth decision making. Lastly, for too long women's decisions are being taken by men so the archaic bar to women joining the Citadel must be reversed in order to allow women to care for women and be armed with as much up to date information as possible.

There is reason for cautious optimism with a woman on the Iron Throne women at the head of many powerful families currently, the time is right to allow the establishment of midwifery as a right for every pregnant woman in Westeros. Couple that with access to evidenced based maester led high risk care. What good is war if there is nobody to carry on the family lineage? Allocation of recently acquired gold would go some way to show the people that women's health is taken seriously by the current administration.